<p> AGENCY FOR PERSONS WITH DISABILITIES CONSUMER DIRECTED CARE PLUS (CDC+) APPLICATION</p><p>SECTION I – PARTICIPANT Participant’s First Name MI </p><p>Participant’s Last Name</p><p>Participant’s Social Security Number Participant’s Date of Birth   / / Participant’s Medicaid ID Number Participant’s Gender  Male  Female Participant’s Race  White  Black  Indian or Alaskan Native  Asian  Latin/Hispanic  Other: ______Participant’s Mailing Address:</p><p>Mailing Address Line 2</p><p>City State Zip Code F L County of Residence Home Phone Number ( ) _ Alternate Phone Number Fax Number ( ) _ ( ) _ Participant’s E-mail Address</p><p>Participant’s Primary Language Written Materials – Language if other than English</p><p>SECTION II – PARTICIPANT’S LEGAL STATUS</p><p>Adult: Legal Representative has authority over medical Minor: Parental Guardian   decisions and/or government benefits  Minor: Other Legal Guardian  Competent Adult: No Legal Guardian Guardian/Legal Representative’s First Name, Middle Initial, Last Name (If none, leave blank)</p><p>Guardian/Legal Representative’s Mailing Address</p><p>City State Zip Code</p><p>Home Phone Number Alternate Phone Number ( ) _ ( ) _</p><p>1 of 2 CDC+ Application Form Effective Date: 09/2/2014 AGENCY FOR PERSONS WITH DISABILITIES CONSUMER DIRECTED CARE PLUS (CDC+) APPLICATION Participant: ______</p><p>SECTION III – CDC+ REPRESENTATIVE (IF NOT NEEDED, LEAVE BLANK)</p><p>Representative First Name M I Representative Last Name</p><p>Representative’s Legal Mailing Address</p><p>City State Zip Code</p><p>Representative’s Home Phone Number Cell Phone Number ( )  ( )  Work or an Alternate Phone Number Fax Number ( )  ( )  Representative’s E-mail Address</p><p>Relationship to Participant  Parent  Spouse  Other Relative  Friend Representative’s Primary Language Written Materials – Language if other than English</p><p>SECTION IV – CDC+ CONSULTANT SELECTION Consultant’s First Name Consultant’s Last Name</p><p>Consultant’s Agency Name (If solo practitioner, enter “SOLO”) Consultant’s Email Address</p><p>SECTION V – IBUDGET COST PLAN (TO BE FILLED OUT BY YOUR CONSULTANT) Most Recent Support Plan Date iBudget PIN / / Current Cost Plan Dates: / / To / /</p><p>Consumer/Guardian/Legal Rep Signature Date Print Name</p><p>Consultant Signature Date Print Consultant Name 2 of 2 CDC+ Application Form Effective Date: 09/2/2014</p>